To report on 4-year postoperative visual performance with the toric implantable collamer lens (TICL) for stable keratoconus after sequential procedure (corneal collagen crosslinking plus TICL implantation).

Five keratoconus patients (10 eyes) that had bilateral AT LISA 939 implantation of were selected and had followed in three-time horizons of 1 and 3months, and 2 years. Patients were 46 to 65 years old age, corneal astigmatism of (2.00 D at 6.75) and cataract that all of them needed cataract surgery. The distance, intermediate and near visual acuities, defocus curve, ocular aberrations, contrast sensitivity, were measured as effectiveness criteria.

At 4-year follow-up, 45% had 20/20 vision or better and 100% had 20/40 or better uncorrected visual acuity (UCVA). Vector analysis of refractive astigmatism shows that the surgically induced astigmatism (SIA) (3.20±1.46 D) was not significantly different from the target induced astigmatism (TIA) (3.14±1.42 D) (p=0.620). At 4 years postoperatively, none of the eyes showed a decrease in UCVA, in contrast to 24 eyes in which UCVA was increased by ≥1 lines, with contrast sensitivity and improvement in total aberrations and MTF value at 5 per degree (*p=0.004) after TICL implantation. The cumulative 4-year corneal endothelial cell loss was ≤5%. No patients reported dissatisfaction. At the end of follow-up, the vault was 658±54.33m (range, 500–711) and the intraocular pressure was 11.7±2.08 mm Hg. Occurrences of glare and night-driving troubles diminished after TICL surgery.

The results from this standardised clinical investigation support TICL implantation from clinical and optical viewpoints in patients with stable keratoconus.